Opportunities for Reform: The Long-Term Care Industry Perspective

James E. Introne

President and CEO

Catholic Health Care System

New York, NY

2

Key Barriers to Reform

No common understanding of what constitutes long term care;

Inability of policy makers to separate long term care reform from Medicaid reform;

Perception of a long term care “industry.”

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What is Long Term Care?

Long Term Care can mean many different things, but any chronic disabling condition that requires nursing home or constant supervision can bring on the need for long term care services.

Long Term Care is the personal care and other related services provided on an extended basis to people who need help with activities of daily living or who need supervision due to a severe cognitive impairment.

Long Term Care, sometimes referred to as elder care, includes a wide range of services that are provided over an extended period of time to people who need help to perform normal activities of daily living because of cognitive impairment or loss of muscular strength or control.

Long Term Care is a variety of services which help meet both the medical and non-medical needs of people with chronic illness or disability who cannot care for themselves for long periods of time.

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Wrong Problem = Wrong Answers

By defining the “problem” in terms of long term care, we address the symptoms rather than the causes: Stiffer fines and penalties More surveillance, investigations and audits Changing the culture Rebalancing Person-centered care Millionaires on Medicaid

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Medicaid as the Principle Funding Source

“All or nothing” nature of Medicaid discourages informal caregiving and the efficient use of resources;

Eligibility determination process discourages and delays needed services;

Lack of integration of Medicaid and Medicare distorts provider decision-making and public policy determinations;

Cost of Medicaid administration and fraud and abuse waste scarce resources.

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Distribution of Elderly Living in the Community at High Risk for Nursing Home Use by Asset Level, 2003*

Assets <$5,000

3+ Years Nursing Facility

Cost7% <1 Year

Nursing Facility Cost 84%

1-3 Years Nursing Facility

Cost9%

Assets $5,000 to < 1 Year Nursing Facility Cost

26%

74%

No Spouse, Age 85+, Functional/Cognitive

Limitation1 Million

Assets Less than 1 Year Nursing Facility Cost

864,022

*Source: Kaiser Commission on Medicaid and the Uninsured: The Distribution of Assets in the Elderly Population Living in the Community. June 2005.

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Perception of a LTC Industry

A diverse provider array includes participants with little in common;

It is impossible for the “industry” to develop standard operating practices;

The differing interests of providers inhibit an effective dialogue on matters of policy;

The “industry” perception marginalizes the advocacy status of nonprofit religious and voluntary providers;

No effective group of advocates for the frail elderly.

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Opportunities for Reform

Create a vision

Refocus on people in need

Expanded integration and care management

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Vision: Implications of the model

*Adapted from C. Evashwick and J. Riedel. 2004. Managing Long Term Care. Foundation of the American College of Healthcare Executives.

Mechanisms of Integration

Inter-Entity Planning and Management

Care Coordination Integrated Information

Systems

Integrated Financing

Skilled nursing

Personal care

Rehabilitation Services

Transportation

Nutrition

Spiritual care

Adult day care

Palliative care

Hospice

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People Who Need Long-Term Care Services, 2000*

Age 65+ 1.5 million

(15%)

Under Age 65 3.5 million

(36%)

Age 65+ 4.5 million

(47%)

Under Age 65 .16 million

(2%)

Total = 9.5 Million

63% are 65 and above37% are under age 65

Community Residents7.9 million

(83%)

Nursing Home Residents 1.6 million (17%)

*Source: Kaiser Commission on Medicaid Facts, July 2006

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Refocus on People in Need

Elderly with physical and cognitive impairments

Developmentally disabled adults

Children with disabilities

Non-elderly adults with disabilities

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Expanded Integration and Care Management

PACE

Medicare Special Needs Plans

State Medicaid Initiatives

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PACE Programs Around the Nation PACE Programs Around the Nation as of April 2007as of April 2007

Source: National PACE Association. PACE and Pre-PACE Programs. www.npaonline.org.

National PACE Association reports 38 PACE providers and 8 Pre-PACE providers nationwide as of April 2007.

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Number of Special Needs Plans*

2006 2007

Dual Eligible 225 310

Institutional 38 85

Chronic 13 74

*Source: Centers for Medicare and Medicaid Services. Special Needs Plan – Fact Sheet and Data Summary. www.cms.hhs.gov/SpecialNeedsPlans/Downloads/FSNPFACT.pdf

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Nursing Home Ownership in 2003

Source: CMS, OSCAR data as of April 2003; N=16,446 facilities.

For-profit, 65%

Not-for-profit, 28%

Government, 6%

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Home Health Care Ownership in 2000*

*Based on distribution of current home health care patients in 2000.

Source: U.S. Department of Health and Human Services, National Center for Health Statistics, National Home and Health Care Survey, 2000.

Proprietary, 34%

Voluntary nonprofit, 57%

Government and other, 9%

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HCBS State Option Provisions in the Deficit Reduction Act

As of January 1, 2007:

States have option of providing package of home and community based services without waiver;

Provide services to people with income up to 150% of poverty level;

No budget neutrality requirement; Option to serve persons who do not require institutional level of

care; Enrollment caps permitted; not required to provide statewide.

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Managed Long-Term Care Programs

State Program Name Population CoveredFL Frail Elder Option (1987) Aged and disabled; NF-level LTC

needs

AZ Arizona Long Term Care System (ALTCS) (1989)

Aged and disabled; NF-level LTC needs

WI Wisconsin Partnership Program (1995) Medically needy elderly or physically disabled adults

MN Senior Health Options (MSHO) (1997) All ages

TX Texas Access Reform (STAR) Plus (1998)

All ages and disabled

WI Family Care (2000) Aged and disabled; NF-level LTC needs

MN MnDHO (2001) All physically disabled

Source: Kitchener, M., Willmott, M., Wong, A., and Harrington, C. (2006). Medicaid Managed Long-Term Care: An Introduction. UCSF National Center for Personal Assistance Services.

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Recent Managed Long-Term Care Programs

State Program Name Population Covered

MA Mass Health Senior Care Options (SCO) (2004)

All ages

FL Integrated Long-Term Care (2005)

Ages 60+

VT Choices for Care (2005) Medically needy elderly or physically disabled adults

Source: Kitchener, M., Willmott, M., Wong, A., and Harrington, C. (2006). Medicaid Managed Long-Term Care: An Introduction. UCSF National Center for Personal Assistance Services.